Programmed inappropriate ICD ventricular defibrillation for cardioversion of persistent atrial fibrillation
© Korantzopoulos et al; licensee BioMed Central Ltd. 2008
Received: 09 August 2008
Accepted: 12 September 2008
Published: 12 September 2008
In this report we briefly describe a patient with a dual chamber implantable cardioverter defibrillator in the context of severe ischemic cardiomyopathy who developed persistent atrial fibrillation. After appropriate anticoagulation and under mild sedation the patient was successfully cardioverted to sinus rhythm after a programmed ventricular synchronized defibrillation using his defibrillator. Programmed internal cardioversion of persistent atrial fibrillation in patients who have an implantable cardioverter defibillator without atrial defibrillation capabilities could be an effective and safe therapeutic option. Unlike external electrical cardioversion, this strategy does not interfere with the implantable cardioverter defibrillator, is more effective, and obviates the need of general anesthesia. This strategy should be further evaluated in clinical trials.
A 73-year-old Caucasian man presented to the outpatient clinic for evaluation of a recent episode of implantable cardioverter defibrillator (ICD) shock therapy. He had been implanted a dual chamber ICD (Model 1871, Vitality DR, Guidant Corp.) for secondary prevention due to resuscitated sustained ventricular tachycardia, not related to a correctable cause, in the context of severe ischemic cardiomyopathy. His past medical history was significant for coronary artery disease (old myocardial infarction and coronary artery bypass surgery), hypertension, diabetes mellitus, and hyperlipidemia. The patient's medications included metoprolol, ramipril, glimepiride, aspirin, and simvastatin.
ICD implantation rates are growing rapidly both for primary and secondary prevention of sudden cardiac death [1, 2]. Given that ICD implantation is increasingly applied in patients with advanced structural heart disease, the prevalence of AF in ICD patients has been increased. Of note, a significant proportion of ICD patients have a history of AF or will develop AF after implantation while paroxysmal or persistent AF in ICD patients has been associated with subsequent appropriate therapy for ventricular arrhythmias [3–5]. Despite technological advances and sophisticated algorithms for improved discrimination between supraventricular and ventricular arrhythmias, inappropriate shocks represent a continuous problem in ICD patients and AF is the most frequent cause .
On the other hand, it is well-known that AF adversely affects myocardial performance, exercise tolerance, and quality of life, especially in patients with heart failure . Moreover, AF per se is associated with increased morbidity and mortality mainly due to embolic events . During the past few years ICDs that offer atrial defribrillator therapy have been developed. However, these devices have not gained wide acceptance . The main reason for this fact is that the conscious patients experience pain during the atrial defibrillation shock. Even low energy shocks in the order of 1 J are uncomfortable for the patients leading to a significant impairment of the quality of life . In other words, their shocks are considered as painful as the standard ICD ventricular defibrillations .
Synchronized electrical cardioversion is the preferable choice of therapy for persistent AF while the pharmacological cardioversion has limited role in this form of AF [9, 10]. In specific, internal defibrillation shocks are preferable and more effective compared to external shocks in ICD patients . Low energy delivered by the internal defibrillation lessens the risk for interference with the ICD programming as well as the risk for endocardial damage whereas the need for general anesthesia is obviated.
Our case demonstrates that programmed ventricular ICD discharge under mild sedation could be an interesting option for quick, effective, and safe cardioversion of persistent AF. Taking into account the aforementioned considerations, this practice may have a particular role in patients with advanced heart failure. Undoubtedly, this strategy should be further evaluated in clinical trials.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written informed consent is available for review by the Editor-in-Chief of this journal.
We are grateful to Mr. George Kokkalidis, Senior Technician of Boston Scientific-Guidant Corp., for his assistance in the management of the patient.
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